Abdominal Pain
Abdominal pain has a wide differential. It is broadly classified into acute and chronic. Although a clear differentiation is not well defined it is generally accepted that >6 weeks is deemed chronic. It is also important to recognize an acute/surgical abdomen in a timely fashion and arrange appropriate speciality involvement. In women with abdominal pain always suspect a gynecologic etiology of the abdominal pain, rule on pregnancy ,and do a pelvic examination if appropriate. History * ChLORIDE FPP: characteristic, location, onset, radiation, intensity, duration, events preceding, frequency, provoking factors, palliating factors * Fever, N/V, weight loss, night sweats, rash * History of trauma * Bowel movements/flatus/diarrhea/constipation blood in stool/ caliber of stool * Urinary symptoms: hematuria, urge, frequency, dysuria, discharge * LMP (female), PV discharge, sexual partners, pregnancy * PMHx: ischemic risk factors, MI, pancreatitis, nephrolithiasis, IBD, ectopic, PID, AAA, diverticulitis * Past Surgical Hx: bowel surgeries (gallbladder/appendix, etc) * Past Obs/Past Gyne History * Medications: NSAID, steroids, OCP/mirena * Social history: smoking, ETOH, rec drugs Physical * ABCs + Vitals * General: dehydration, discomfort * Abdominal exam: ausculate for bowel sounds), percuss, palpation (light/deep)- masses, rebound, guarding, peritoneal signs * +/- Genitals: pelvic, testicles * +/- DRE: masses, rectal tone, blood * +/- Extra-stigmata of liver disease Differential RUQ * Hepatitis, gall bladder disease, right lower lobe pneumonia, intestinal ischemia, appendicitis, liver abscess, liver/pancreatic/biliary cancer, pyelonephritis, urinary calculi, trauma or MSK pain, abdominal abscess, herpes zoster, dyspepsia Epigastric * Dyspepsia, PUD, GERD, gastritis, myocardial infarction, pneumonia, pancreatitis, pancreatic Ca, gall bladder disease, esophageal rupture, gastric volvulus, aortic dissection LUQ * Gastritis, pancreatitis, PUD, LLL pneumonia, MI, pyelonephritis, ruptured spleen, splenic infarct, diverticulitis, trauma/MSK Periumbilical * obstruction, gastroenteritis, pancreatitis, aortic dissection, MI, early appendicitis RLQ * Appendicitis, IBD, IBS, PID, ovarian torsion, ruptured ovarian cyst, tubo-ovarian abscess, endometriosis, ectopic, mittelschmerz, cystitis, hernia, testicular torsion, epididymitis, prostatisis, diverticulitis, urinary calculi, obstruction, AAA, mesenteric adenitis, trauma/MSK, abdominal abscess LLQ * Diverticulitis, colitis, constipation, obstruction, IBS, gyne (ovarian torsion/cyst/PID, ectopic, endometriosis, mittelschmerz), intestinal ischemia, cystitis, hernia, testicular (torsion, epididymitis), prostatitis, urinary calculi, trauma/MSK, AAA GI Tract * Infectious/Inflammatory: IBD, gastroenteritis, gastritis, esophagitis, appendicitis, colitis, diverticulitis * Obstruction: small bowel obstruction, large bowel obstruction, malignancies, volvulus, hernia, intussusception, constipation, adhesions * Digestion: peptic ulcer disease, lactose intolerance, celiac disease, food allergies, functional dyspepsia * Other: hemorrhoids, mesenteric ischemia, IBS Hepatobiliary * Hepatic: hepatitis, hepatic abscess, malignancy, hepatic vein thrombosis * Gallbladder: cholelithiasis, cholecystitis, choledocholithiasis, malignancy * Pancreas: pancreatitis, pseudocyst, malignancy Renal/Bladder/Urinary System * Pyelonephritis, kidney stones, cystitis, urinary retention, malignancy * Testicular torsion, epididymitis, prostatitis Gynecologic * PID, ovarian torsion, tubo-ovarian abscess, ovarian cyst, endometriosis, fibroids, ectopic, spontaneous abortion, menstruation, mittelschmerz, malignancy, uterine rupture Vascular * AAA, aortic dissection, vasculitis, thrombosis/embolism, mesenteric ischemia Other * MSK pain/strain/trauma * Neurogenic pain: zoster, nerve entrapment * Referred pain: pneumonia, PE, MI, pericarditis, spine, testicles * Metabolic: DKA, uremia, withdrawal Investigations * Depend on history and physical * Can include: CBC, lytes, BUN, Cr, LFTs, bilirubin,lipase, amylase,glucose, lactate, T+S, TTG, anti-IgA, ESR/CRP, urine R+M, urine C+S, urine or serum BhCG, +/- septic w/u * Plain film (3 views of abdomen): free air, obstruction * Ultrasound: biliary tree, liver, gynecologic, testicular, AAA, hydronephrosis, appendicitis (young,thin) * CT adbdomen * Further investigations: ERCP/MRCP, MRI abdo, colonoscopy, endoscopy Inflammatory Bowel Disease Crohn's disease * Pathophysiology: transmural inflammation of GI tract * Clinical: crampy abdominal pain, prolonged diarrhea +/- blood (often occult), fatigue, weight loss, +/- fever * Can be associated with: ** strictures and SBO ** fistulas (communications often between intestine and bladder/skin/bowel/vagina - enterovesical/enterocutaneous/enteroenteric/enterovaginal) ** abscess ** perianal disease: pain, drainage, anal fissure, perirectal abscesses, anorectal fistulas ** malabsorption (bile acids) ** Other GI involvement: amphthous ulcers, odynophagia, dysphagia * Extraintestinal manifestions: arthritis (sacroilitis, ankylosing spondylitis), eye (uveitis, iritis, episcleritis), skin (erythema nodosum, pyoderma gangrenosum, primary sclerosing cholangitis, renal stones, osteoporosis, vitamin B12 deficiency, venous/arterial thromboembolism, cholelithiasis, Fat soluble vitamin malabsorption (ADEK), pulmonary (bronchiectasis, ILD) * Investigations: ** CBC, lytes, Cr, Liver enzymes, blood glucose, ESR, CRP, iron studies, B12, albumin (CRP levels correlate with crohn's activity) ** Consider celiac serology, stool testing for culture, ova and parasites, c.diff (pending history) ** Colonscopy with biopsy ''' ** CT: strictures ** MRI: perianal fistulas ** Small bowel disease: upper GI series with small bowel follow-through (barium study - string sign, cobblestoning), CT, CTE, MRI, MRE, enterocysis * Prognosis: May have slight increase risk of colorectal cancern, no change in mortality. Typical course: exacerbations and remissions. Not medically or surgically curable * Treatment: ** Depends on severity *** Adults: Crohn's Disease Activity Index (CDAI) and the Harvey-Bradshaw Index (HBI) *** Pediatrics: Pediatric Ulcerative Colitis Activity Index (PUCAI) ** 5 -ASA (mild-moderate) - although poor evidence (Sulfasalazine, mesalamine). Recommended as maintenance therapy. ** Steroids (flare-up): prednisone/budesonide ** Immunosupressants: azathioprine (imuran), MTX - treat active inflammation, maintain remission ** Antibiotics (Metronidazole) for decrease disease activity, perianal disease, fistula, abscess ** Immunomodulators/biologics: infliximab - remicade, adalimumab - Humira ** Surgical: obstruction, fistula ** Other: *** Antidiarrheal medications — loperamide, cholestyramine (chronic watery diarrhea or previous ileal resections)Ileal disease - risk of lactose intolerance ** Routine: *** Diet counseling/supplementation: Ensure adequate calcium, Vitamin D, Magnesium, Zinc, B12, iron *** Osteoporosis prevention: smoking cessation, calcium, Vit D, exercise, +/- bisphosphonate *** Immunizations UTD, yearly influenza *** Screening for colon cancer - colonoscopy q 5-10 years *** Prior to starting biologics: hepatitis serology,+/- HIV, CBC, metabolic profile with LFTS, Cr, screen for latent TB, immunizations >3 months prior to starting Ulcerative Colitis ***** Gastroesophageal Reflux * Clinical: epigastric/retrosternal burning discomfort, worse after meals (especially fatty/spicy/caffeine), worse with lying down/bending over, +/- regurge symptoms, waterbrash, dysphagia * Extra-esophageal complications: cough, dental erosions, pulmonary fibrosis (rare), bronchitis, laryngitis, dental erosions, sinusitis * Red flags: GI bleeding, anemia, vomiting, dysphagia, chest pain, weight loss * Pathophysiology: lower esophageal sphincter dysfunction, delayed gastric emptying * Complications: esophagitis, peptic stricture, Barrett's esophagus (increase risk of adenocarcinoma) * Diagnosis: based on history and improvement with treatment. Further investigation if atypical symptoms, not relieved with medication, red flags. Consider endoscopy in patients with > 10 years of reflux. ** CBC (R/O anemia) ** GOLD STANDARD - 24 hour pH monitoring (rarely completed) ** '''Endoscopy (biopsy): '''atypical symptoms, alarm symptoms, failure to respond to treatment after 4-8 weeks of treatment, dysphagia that does not resolve within 2-4 weeks of PPI * Treatment: ** Non-pharm: avoid spicy/citris foods, fatty foods, chocolate, caffeine, ETOH, smoking. Lose weight. Elevate head of bed. Small, frequent meals. Avoid lying down for > 2 hours post meal. Consider changing medications that affect LES tone. ** Pharm: antacids, H2 antagonists(e.g. ranitidine), PPI (e.g. pantoprazole), pro-kinetic agents (e.g.metoclopramide) *** R/A PPI in 4-8 weeks. Consider titration and then D/C at that point. *** Risk of chronic PPI use: osteoporosis, hip #, community acquired pneumonia, c.difficile, gastric acid rebound on discontinuation, iron deficiency, low magnesium, B12 deficiency Peptic Ulcer Disease * Clinical: upper abdominal pain gnawing/burning, pain improved with meals,pain occuring 2-5 hours after a meal,nocturnal pain, nausea, bloating, early satiety * Red flags: vomiting, UGIB, anemia, abdominal mass, unexplained weight loss, dysphagia * Etiology: NSAIDs (often gastric), helicobacter pylori (often antral or duodenal), acid secreting tumors. * Complications: UGIB, perforation, gastric outlet obstruction * Investigations: ** CBC (R/O anemia) +/- FOBT ** H.Pylori: serum ELISA test (serology), Urea breath test, stool antigen test, endoscopic biopsy *** Serum ELISA testing least accurate and only useful for initial infection ** Endoscopy (>50 years old, alarm symptoms, fail treatment therapy, NSAID use) ** Acute ill CXR upright to r/o free air (perforation) * Treatment: ** non-pharm: avoid ETOH, smoking, NSAIDs ** PPI or H2 receptor antagonist x 4 weeks then R/A ** H.Pylori treatment: combination therapy with a PPI BID (triple therapy) *** Amoxicillin 1000mg PO BID + Clarithromycin 500mg PO BID x 1 week *** Clarithromycin 500mg PO BID + Metronidazole 500mg PO BID x 1 week *** Second line: PPI BID + Metronidazole** 500mg PO BID + Amoxicillin 1000mg PO BID (note Levofloxacin 500 mg PO daily can be substituted for metronidazole in treatment refractory H. pylori) *** Quadruple therapy: PPI + bimuth + metronidazole + tetracycline x 10-14 days ** Endoscopic: bleeding sites can be ligated, clips placed, epinephrine injected ** Refractory: surgical options * Post-treatment: ** If asymptomatic - no further investigations ** If remains symptomatic retest using urea breath test >30 days (2 weeks off PPI, 1 month of abx) Biliary Disease Risk factors *F's: Fat, female, fertile, forties Cholilithiasis (gallstones) *Only 10% of people with gallstones will display symptoms Biliary colic *Clinical: RUQ pain, usually constant in nature, intense/dull discomfort, pain often associated with diaphoresis, N/V,not relieved with movement/bowel movement, often precipitated by eating a fatty meal, post-prandial pain, lasts on average 30minutes- <6 hours, afebrile, normal physical examination, normal laboratory values *Pathophysiology: stone forced into gallbladder outlet, leading in increase in gallbladder pressure. As gallbladder relaxes, stone moves out of outlet. *Investigations: ultrasound, (if negative and classic symptoms usually repeat U/S in 2-3 weeks). If negative could consider endoscopic ultrasound, r/o other non-biliary tree pathology *Management: conservative management with close follow up or referral to general surgery for cholecystectomy *Complications of cholecystectomy: bleeding, abscess formation, bile leak, biliary injury, bowel injury, chronic diarrhea Acute Cholecystitis *Clinical: biliary colic complicated by infection and inflammation of gall bladder. Assc with N/V/fever, localized peritonitis, + Murphy's sign, elevated WBC/LFTs *Investigations: ultrasound (GB thickening, pericholecystic fluid), +/- blood cultures *Management: admit, consult general surgery, NPO, correct electrolyte disturbances, IV fluids, analgesia, +/- Abx, NG insertion (if persistent emesis), cholecystectomy or gallbladder drainage procedures **Selection and timing of definitive management depends on severity of symptoms, duration of symptoms, and surgical risk *Antibiotic options: ** Ceftriaxone 1g IV q24h + Metronidazole 500mg IV/PO q8h ** Ciprofloxacin 400mg IV/500mg PO q8h + Metronidazole 500mg IV/PO q8h Choledocholithiasis *Presence of gallbladder stones in common bile duct * Clinical: biliary type pain, elevated cholestatic liver enzymes (GGT, ALP), AST/ALT (elevated early), '''jaundice, courvoisier sign (palpable gallbladder often associated with malignancy) **Uncomplicated: afebrile, N CBC **Complicated: acute cholangitis (fever, elevated WBC), gallstone pancreatitis (elevated lipase) * Investigations: CBC, LFTs, bilirubin, +/- blood cultures, Ultrasound (bile duct dilatation >6mm) ** Further imaging: endoscopic ultrasound, MRCP, ERCP * Management: ** High risk: ERCP + elective cholecystectomy. Other option: cholecystectomy with intraoperative with interoperative cholangiography - followed by intraoperative or post-op ERCP ** Moderate risk: pre-op endoscopic ultrasound or MRCP ** Low risk: direct to cholecystectomy Ascending Cholangitis *Complete obstruction of infected biliary tree *Etiology of obstruction: gallstones, strictures, malignancy, stent *Charcot's triad: RUQ pain, fever, jaundice *Reynold's Pentad: fever, RUQ pain, jaundice, shock, confusion *Investigations: Elevated CBC, elevated LFTs, + blood cultures, Ultrasound (duct dilatation) *Treatment: urgent endoscopic decompression (drainage), + broad spectrum ABx (same as cholecystitis)+ monitoring/treatment of sepsis Pancreatitis *Etiology: I GET SMASHED:' i'diopathic, gallstones, ETOH, Tumors, Scorpion bite, microbiology (mumps), Autoimmune, Surgery/Trauma (ERCP), Hypertriglyceridemia/hypercalcemia/hypotherapy, Emboli/ischemia, Drugs *Clinical: N/V, fever, epigastric pain radiating to the back, loss of appetite, hemodynamic instability, jaundice, cullen's sign (hemorrhagic blue discolaration of umbilicus), grery turner (flank discoloration) *Complications: ARDS, pleural effusion, pseudocyst, pancreatic abscess, pancreatic necrosis, chronic pancreatitis ***** Bowel Obstruction Diverticulitis *Imaging: CT abdo *Management: **Mild/moderate: fluid -->DAT, PO Abx (cipro/flagyl) **Moderate/severe: requires imaging, consult general surgery, Abx, NPO Appendicitis * Epidemiology: M>F, highest incidence age 10-30s * History: Periumbulical pain--> RLQ pain, fever, anorexia, N/V * Physical: fever, RUQ tenderness ** McBurney's point (maximal tenderness 2 inches from ASIS on straight line from ASIS to umbilicus ** Rovsing's sign: pain in RLQ with palpation to LLQ ** Psoas sign (retrocecal appendix): RLQ pain with passive right hip extension ** Obturator sign (pelvic appendix): flex right hip/knee + internal rotation = RLQ pain * Investigations/Imaging: ** Blood work: mild leukocytosis with left shift, T+S ** CT abdomen ** Ultrasound (not as specific) - could consider first line * Management: ** Abx - cipro/flagyl or ceftriaxone/flagyl ** NPO, IVF, analgesics ** Consult general surgery for appendectomy Irritable Bowel Syndrome Abdominal Aortic Aneurysm Resources http://www.aafp.org/afp/2007/1001/p1005.html